Part I. The Context: Overwhelmingly Negative Reactions to Publication of DSM-5

This week, the American Psychiatric Association is holding its annual convention in San Francisco, and this is not your ordinary gathering of psychiatrists. This convention inaugurates the launching of the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders, or the DSM-5. If you have been following the Facebook page of the Society for Humanistic Psychology, you are all too aware that I have been closely monitoring news coverage of the DSM-5 launch (my apologies if your news feed has been unduly littered by DSM-5 related news).

Photo courtesy zirconicusso / freedigitalphotos.net

One thing is abundantly clear: The news coverage of the DSM-5 is, almost without exception, overwhelmingly negative press. The journalistic headlines and story angles paint a clear picture that the DSM-5 is anything but a document to be celebrated. The tone, rather, is that we have a guidebook on diagnosis that is fraught with controversy. For example, Dave Templeton interviewed me for a story in the Pittsburgh Post-Gazette , and he also interviewed DSM-5 Chair, David Kupfer. In the interview, I felt I gave a very nuanced and fair reading of the state of the field, and refrained with professional restraint from any kind of polemics. Yet, what was the headline? “Critics blast new manual on mental disorders.” Is this sensationalism? Absolutely not. If there ever was a truth to news, the journalists have it right: Just about everyone hates the DSM-5.

Among the critics, perhaps the most influential has been Allen Frances , Chair of the DSM-IV Task Force and Thomas Insell, Director of the National Institute of Mental Health. Francis has been relentless in his criticism over DSM-5’s lowering of diagnostic thresholds, reckless inclusion of new diagnostic categories with little empirical support, and embarrassingly poor reliability and validity. Thomas Insell rocked the world of psychiatry several weeks ago when he announced that DSM-5 diagnostic categories lack scientific validity, and that NIMH would no longer support research based on DSM classification (see here). Most commentators rightly viewed this as a death blow to the future of the DSM approach to classification (see for example Hank Campbell’s blog post here).

These critics are important because, unlike other legitimate critics, they cannot be easily dismissed as “anti-psychiatry” or as mental health professionals in a “guild dispute” with psychiatry. They are psychiatrists, and they represent mainstream psychiatric institutions – the DSM-IV and NIMH, respectively. It would be ludicrous to suggest they are trying to discredit the field of psychiatry. Quite the contrary, they are trying to save it from ruin.

Likewise, a very important moment in the growing negative attitude toward DSM-5 was the “Open Letter to DSM-5,” which was sponsored by the Society for Humanistic Psychology, Division 32 of the American Psychological Association. The “Open Letter” was endorsed by over 50 international mental health institutions, and signed by about 15,000 individuals, the great majority of whom are mental health professionals. Another important and influential voice was the British Psychological Society, which was among the first in the world to author a systematic critique of the DSM-5 in their own letter to the American Psychiatric Association. These voices have now joined together both in critique of the DSM-5 and in the generation of international dialogue to explore better alternatives to current diagnostic practices. The DSM-5 Response Committee , which is spearheaded by Peter Kinderman and myself, is focused on the critique of DSM-5, and the International Diagnostic Summit Committee , led by Frank Farley and Jonathan Raskin, is focused on creating forums for international dialogue on better alternatives to current diagnostic practice. Note that the websites for these efforts contain a wealth of information—so make sure to check them out.

These examples are the tip of the iceberg. News story after news story, blog after blog by professional commentators, overwhelmingly converge in universal condemnation of the DSM-5. The emerging consensus is that the DSM-5 lacks scientific reliability and validity, which compromises public safety. Yet, what is the alternative? What we have, basically, is a diagnostic vacuum. What will fill the vacuum?

Part II. The Future of Diagnosis in Clinical Psychiatry and Psychology

On my radar, I have identified four different major projects that are getting underway, and each telegraphs the future of diagnosis in clinical psychiatry and psychology.

First, Allen Frances is playing a major role in a MOOC (Massive Open Online Course) designed to help minimize damage from the DSM-5. The MOOC has been developed by Thomas Nickel, Director of Continuing Education at Alliant University. I’ve been in touch with Nickel, and we are working on ways that Society for Humanistic Psychology’s initiatives can contribute to, and be informed by this MOOC project. I already did a short interview with Nickel that is available on the website. But I think, beyond that, there may be some very creative ways to use this forum to help foster international dialogue to help those who are required to use the DSM-5. Information and forums for discussion can serve as potential ways to help minimize possible damage that could result from mis-use of the DSM-5 manual, such as iatrogenic side effects from unnecessary medication of the over-diagnosed.

Secondly, in a development that I believe has great promise, The British Psychological Society, and Peter Kinderman in his blogs at the International Diagnostic Summit, are calling for a problem-based, case formulation alternative to the DSM approach to diagnosis. Allen Frances has already criticized this initiative by claiming that BPS is prioritizing psychosocial etiology over against bio-medical etiologies (see here. I have been working very closely with Kinderman, and it is clear to me that Frances has misunderstood the BPS proposal, at least as it is has been articulated by Kinderman.

A problem-based approach does not reject all bio-medical explanations, nor does it endorse one. It is a theoretically neutral approach which does not presume etiology – therefore, it endorses neither a purely biological nor a psychosocial approach. Rather, it is empirically and pragmatically driven. What it rejects are unreliable, invalid diagnostic categories based on a syndrome model in which symptoms that co-occur are presumed to point toward an underlying disease. As Insel at NIMH has noted, the science does not support that claim.

A problem-focused approach begins with a description of the client’s problem, such as hearing voices, being afraid to leave the house, or suicidal thoughts, for example. Once a problem is identified and formalized, a case formulation approach can investigate potential antecedents, which may be biological, psychological or social in nature – or some combination of these – and the conclusions regarding etiology should drive treatment decisions. If that is what the clinician is doing, the addition of a diagnostic label is completely unnecessary, and in fact, may be quite likely to obscure the matter. The addition of a label runs the risk of creating an explanatory fiction that masquerades as an explanation of the problem when, in fact, it is just a re-branding of the problem in different terms with the presumption of an underlying disease process that is attributed to a psychological or biological flaw in the person. A problem-based approach can be open to that possibility, but it will also be receptive to the likelihood that a person’s problem may not be attributable to the individual, but rather to that person’s situation. Sometimes the person who appears abnormal is actually reacting normally to an abnormal situation.

For example, a person who is grieving is not flawed in any way, but is reacting in a typical and expected way to the loss of an attachment figure. The person likely will need support and care because they are suffering with the problems of bereavement, but it would be superfluous and even an assault on the bereaved person’s dignity to presume grief was attributable to some flaw in the person’s psyche or soma.

Among the current directions in diagnosis, I am inclined to say that the problem-based, case formulation approach holds the most promise for a scientifically sound, theoretically open-ended, and inclusive approach to diagnosis that could be embraced by all mental health professions. The approach also lends itself quite well to a client- or patient-centered model of care, as well as recovery models of mental health, which are on the ascendancy in the United States and abroad – much to the credit of decades of hard-fought victories by humanistically-oriented mental health practitioners and consumers.

Also, very important to mention: really, isn’t a problem-based, case formulation approach the way most effective clinicians actually practice their craft in the real world? And isn’t it true that in most cases, a diagnostic label is an after-thought with the primary function being to justify reimbursement from insurance companies, or other bureaucratic systems within which we work? If so, let’s stop lying about what we do, and articulate in a clear, systematic way what we are really doing when we help people who are suffering.

The third initiative is the Research Domain Criteria (RDoC) project, which is the focus of the NIMH. Like the problem-based approach advocated by BPS, the RDoC also rejects the DSM syndrome model approach to diagnosis, and agrees that DSM categories lack scientific validity. However, whereas the problem-based approach is theoretically neutral and open-ended, NIMH presumes a biologically reductive approach to diagnosis and a bio-medical etiology of psychiatric problems. I feel strongly that NIMH’s project is doomed to failure, but I will leave that argument for a future blog. Suffice it to say for now: Of course there are biological dimensions of all psychological processes. But how does the NIHM decide when biological differences are normal or abnormal? That decision is impossible without understanding the psychological and social context in which a person’s biology is functioning. What may appear biologically functional in one context may be dysfunctional in a different context. I will have more to say on that later in a future blog.

And last but not least: Helen B. Hansen, Assistant Professor of Psychiatry and Anthropology at New York University, and a group of like-minded colleagues are calling for an independent review of social and population variation in mental health in order to improve future DSM revisions, or presumably any alternative system of diagnosis that may appear on the scene in the future. Such a group would pay attention to the many, often ignored factors that can influence the way diagnoses are framed and applied, including, for example, pharmaceutical marketing and advertising, insurance reimbursement, socio-economics, sexism, racism, and guild disputes. I applaud their efforts, and pledge that, as President of the Society for Humanistic Psychology, I would support and participate in any such effort with great enthusiasm, and I encourage others to do the same.

These are all important developments that point toward likely future directions in the field. I, for one, will be keep a close eye on all of these developments. We are indeed living in an exciting and interesting time for mental health diagnosis. Many years from now, I have no doubt, generations will look back on this moment as a pivotal age when psychiatric and clinical diagnosis took a radical turn. Let’s not just hope it turns out well – let’s work together to make sure it does.

Brent Dean Robbins, Ph.D. is an associate professor of psychology and coordinator of the psychology program at Point Park. He is editor-in-chief of Janus Head: Journal of Interdisciplinary Studies in Literature, Continental Philosophy, and Phenomenological Psychology, and a recipient of the American Psychological Association's Carmi Harari Early Career Award. His published research includes mixed method investigations of emotion, embodiment, and the medicalization of the body in contemporary Western culture, with particular attention to the implications of these findings for the treatment of mental illness.

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6 Comments Already

Eric Maisel-May 23rd, 2013 at 2:54 pmnone
Comment author #29 on After the DSM-5, Then What? The Future of Diagnosis in Psychiatry and Clinical Psychology by Global Summit on Diagnostic Alternatives

I agree. A problem-solving approach is more sensible, humane, and pragmatic. I think that, unless carefully thought out, it also has the potential to prove too simple and too psychologically unsophisticated. I think that we might want to think through a different model, a “collaborative” model, which includes problem-solving but which also includes some of the tactics of coaching, like cheerleading and exhorting, and which takes into account our human penchant for not naming our problems accurately (problems with self-reports) and not wanting to make the changes that might improve our lives (resistance to change). I’ll be writing about this “collaborative” model in some future posts of mine …

Brent Dean Robbins-June 4th, 2013 at 1:21 amnone
Comment author #73 on After the DSM-5, Then What? The Future of Diagnosis in Psychiatry and Clinical Psychology by Global Summit on Diagnostic Alternatives

Eric, I look forward to your reflections on a “collaborative model.” I should point out, however, that I do envision a problem-based approach to be best implemented in a collaborative way. I was taught by Constance Fischer at Duquesne University. She was one of the pioneers of collaborative assessment, and her humanistic approach provides a perfect foundation for a client-centered, collaborative approach to a problem-based diagnostic strategy. In addition, I would add that a strength-based approach to treatment is one I am also inclined to endorse. I’ll have more to say about these matters in future blogs.

Ronald Pies MD-May 24th, 2013 at 7:59 pmnone
Comment author #31 on After the DSM-5, Then What? The Future of Diagnosis in Psychiatry and Clinical Psychology by Global Summit on Diagnostic Alternatives

I agree with that suffering and incapacity in the emotional/cognitive/behavioral realm does not typically sort itself out into neat “categories”, in the manner suggested by the DSMs; indeed, while I don’t discount a categorical approach for some conditions (e.g., Alzheimer’s Disease or bipolar I disorder) I favor a more prototypical/ phenomenological approach to diagnosis, for everyday clinical work. Reification of the DSM categories–or those of the ICD system–can sometimes be misleading and clinically unhelpful.

That said, a completely “adiagnostic” approach cannot be supported, for ethical, legal and clinical reasons. A patient who complains, e.g., of “auditory hallucinations” may be (1) suffering from a brain tumor affecting the temporal lobes; (2) abusing hallucinogens;(3) suffering from what the DSMs would call schizophrenia; or (4) experiencing complex partial seizures. To just the extent that Prof. Kinderman wants us to form a “hypothesis about
[the] origins” of the patient’s problem, he is inevitably compelling us to engage in diagnosis–a word that literally means, “knowing the difference between.” We must know the difference between–or among–diverse etiologies in order to formulate the very therapeutic solutions that Prof. Kinderman calls for (e.g., brain surgery? drug detox? antipsychotic medication? anticonvulsant?).

For more on the role of “convergent validity” in psychiatric diagnosis, please see the important comments by Dr. Bernard Carroll, quoted in Dr. Allen Frances’s latest blog:

Brent Dean Robbins-June 4th, 2013 at 1:50 amnone
Comment author #74 on After the DSM-5, Then What? The Future of Diagnosis in Psychiatry and Clinical Psychology by Global Summit on Diagnostic Alternatives

Ron, I think there is some confusion about how “diagnosis” gets defined. You seem to like to quote Wittgenstein, so you might also be familiar with Lyotard who talked about the problem of the “differend”. The “differend” is a term that leads to confusion because one, dominant language game (in this case, the DSM approach to “diagnosis”) marginalizes any other, legitimate use of the term “diagnosis” within a different language game. This is a way that structures of power maintain their power, through the marginalization of minority perspectives — that is, through the marginalization of minority language games.

To “diagnose” simply means to make a discernment about the nature and cause of an event, medical or otherwise. The term is more commonly used to discuss medicine, but it can be used for any problem-solving endeavor. The DSM however is an approach to diagnosis that does not identify the nature or cause of a set of problems — it simply gives them an abstract label. It is important not to equivocate between these two uses of the term “diagnose.”

When Kinderman rejects the term “schizophrenia,” he is rejecting the definition of “diagnosis” as a mere label that serves as a pseudo-explanation for a set of symptoms. This occurs when symptoms such as auditory hallucinations, for example, are diagnosed in relation to other symptoms and then provided with the label, “schizophrenia.” The question is, does the label “schizophrenia” add any new information? I agree with Kinderman that the answer is no. In fact, the label has a tendency to obscure rather than clarify the nature and causes of auditory hallucinations. Here, clearly, Kinderman rejects the DSM notion of “diagnosis” with regard to schizophrenia.

It seems perfectly clear to me, however, that even while Kinderman rejects psychatriac labels, he is not rejecting diagnosis in the larger sense of identifying the nature and causes of psychological problems. He seems quite open to the idea that auditory hallucinations may very well be discovered to have an underlying pathophysiological explanation, such as a tumor. However, the label of “schizophrenia” is not equivalent to the diagnosis of tumors, because unlike with the case of a tumor or seizure, schizophrenia has no equivalent, clear, and undeniable biological basis as far as we know.

Brain tumors, intoxication from hallucinogens and complex partial seizures are all legitimate diagnoses in that they identify the underlying nature and cause of the problem, which in this case is auditory hallucinations. However, the label “schizophrenia” does not identify an underlying nature nor cause of the auditory hallucinations — it merely substitutes the description of the problem with an invalid, pseudo-explanation in the form of a pseudo-scientific diagnostic label. The former should not be confused with the latter — which results in the differend problem noted above. The differend “diagnosis” has different meanings in the two different language games. The way DSM defines “diagnosis” may, for example, work to serve a legitimizing function, such as allowing psychiatry to straddle the fence between psychology and neuroscience — the mirror trick identified quite brilliantly in Sarah Kamens’ recent blog.

In your list of “diagnoses,” Ron, the schizophrenia label is a completely different animal than a tumor, ingestion of a chemical, or a complex seizure. If you’ve ever seen Sesame Street, you can sing along with me: one of these things is not like the others.

Ronald Pies MD-June 5th, 2013 at 8:16 pmnone
Comment author #79 on After the DSM-5, Then What? The Future of Diagnosis in Psychiatry and Clinical Psychology by Global Summit on Diagnostic Alternatives

[Please see footnotes at bottom]

Thanks for your thoughtful comments, Brent. I do agree with you that “diagnosis” sometimes–underline, “sometimes”– entails “discernment about the nature and cause of an event” or condition. (And, I suspect that Prof. Kinderman would agree). But that definition is often too restrictive, and is no more “legitimate” than other, more flexible definitions, used for centuries in general medicine.

The term “diagnosis” literally means, “knowing the difference between” (dia-across, between; gnosis, knowledge). While we physicians always hope to know, or eventually learn, the “cause” of a patient’s presenting problem or condition, we are not always so fortunate! That emphatically does not make the diagnosis, or the diagnostic process, less “legitimate.” Many diagnoses in medicine, historically speaking, were “descriptive”, not “causal”–often for many centuries, before we discovered the cause or causes, or understood the pathophysiology. These were not “pseudo” diagnoses or pseudo- anything. They were merely incomplete, provisional, and syndromal diagnoses.

Let’s take the example of migraine headache. The term is derived from the Greek, hemikrania, meaning “half the head.” This expresses the well-known manifestation of migraine headache on one side of the patient’s head. To this day, we do not know the precise pathophysiology of migraine headache, nor is there a “lab test”, X-ray, or “biomarker” that enables us to say with certainty that migraine is the “correct” diagnosis. Yet every neurologist will tell you that this is a very real, debilitating affliction, and a perfectly “legitimate” diagnosis. The diagnosis is made–let us be clear–on the basis of what the patient tells the physician; e.g., “I get terrible pain on one side of my head, Doc…it usually is accompanied by nausea…I see sparkling lights in my field of vision…” etc. The term “migraine” then comes to embrace these syndromal features. Yet the diagnosis is both meaningful and descriptive–and legitimate. It also has high predictive validity (in terms of disability, response to treatment, etc.). Yet the term “migraine” does not point to the “underlying nature” or “cause” of the condition, which remains–to this day!–rather obscure, despite dozens of unproved hypotheses involving serotonin, vasoconstriction, etc.

The same argument applies to the diagnosis, e.g., of “tic douloureux” (trigeminal neuralgia), whose precise pathophysiology is not well-understood, and whose name–basically, “painful tic”–is descriptive, not etiological. Yet the syndrome has been recognized for centuries; has a clear set of syndromal features; and a relatively predictable course and response to treatment. These “properties” of the diagnosis confer validity on it, and make the term clinically useful to physicians.

For all these reasons, it is incorrect and deeply misleading to refer to such descriptive/syndromal diagnoses as “pseudo-scientific labels.” This is why Tom Insel was wrong–in fact, why he was being “unscientific”!–when he thoughtlessly declared the DSM-5 to be “not valid.” He did not understand–or care to acknowledge–that biological validity is merely one subtype of validity. Ultimately, we aim for biological validity, but it is neither necessary nor sufficient for the ascription of “disease” or “disorder.”

Similarly, while nobody in my profession likes the term “schizophrenia”–etymologically, “divided mind”–it is a legitimate and reasonably useful term, in so far as it describes a moderately coherent syndrome with a recognized (albeit variable) course;^^ associated co-morbidity (such as increased risk of cardiac disease); familial (and probably genetic) pattern; and response to treatment (i.e., antipsychotic medication helps reduce at least some symptoms) (refs. 1,2). It is simply incorrect, Brent, to assert that the term “schizophrenia” adds no new information to a mere list of the patient’s symptoms, just because the term does not add etiological information.^^

We could re-name schizophrenia, “Bleuler’s Syndrome” or “Aberrant cognition and belief disorder”, but the extraordinary suffering and incapacity associated with the condition would be unchanged. There is nothing “pseudo-scientific” about using a short-hand, descriptive, syndromal term, if you understand what “science” is, and what the scientific method means. Most critics of psychiatry understand neither. Science is not synonymous with “biology” or with biomarkers, etc. The deification of biomarkers and biological etiology is a form of scientism, not science!

What is science, then?

As philosopher Samir Okasha puts it, reflecting Wittgenstein’s view** that words do not have “essential” definition, but may have certain “family resemblances”,

“…science is a heterogeneous activity, encompassing a wide range of different disciplines and theories. It may be that they share some fixed set of features that define what it is to be a science, but it may not.” [Okasha S: Philosophy of Science. Oxford University Press, 2002, pp. 16-17.]

Recently, the British Science Council spent a full year developing a definition of “science.”
Their work-product is succinct and yet radically insightful: “Science is the pursuit of knowledge and understanding of the natural and social world following a systematic methodology based on evidence.”
[http://www.guardian.co.uk/science/blog/2009/mar/03/science-definition-council-francis-bacon]

There is simply no question that psychiatric diagnosis entails a “systematic methodology based on
evidence”–and that this need not entail, in all instances, recourse to biological etiology.

As one of the great pioneers in biomarker research in psychiatry, Dr. Bernard Carroll–developer of the
dexamethasone suppression test– has put it,

“We need to be clear that the existence of disease is not predicated on having a biological test. It’s nice when we do have one, but there are many areas in medicine where there is no conclusive diagnostic test. Think migraine. Think multiple sclerosis. Think chronic pain. Indeed, clinical science correctly recognized many diseases long before lab tests came along for confirmatory diagnostic application. Think Parkinson’s disease, Huntington’s disease, epilepsy… it’s a long list.”
(Carroll BJ. Comment on Medscape. http://www.medscape.com/viewarticle/804408?nlid=31347_421&src=wnl_edit_medp_psyc&uac=200FZ&spon=1).

Indeed, as Carroll notes, a biomarker can never be “better” than the clinical criteria for which the lab test is
designed. And the validity of those criteria rests on non-biological elements; i.e., construct validity, discriminant validity, and predictive validity.

That we now–after many centuries–have some biological and neurological understanding of some of these conditions, such as Parkinson’s disease, does not mean that, when James Parkinson made the diagnosis of “shaking palsy” in 1817, he was making an “illegitimate” or “pseudo-scientific” diagnosis! Mutatis mutandis, as my old friend Tom Szasz used to say, when we say that someone has “schizophrenia”, we are certainly saying something provisional, imperfect, and incomplete–but still legitimate.

With more time and more knowledge, Brent, we will do better. In the mean time, we have suffering and incapacitated patients who need our help, imperfect though our diagnoses and treatments may be.

Best regards,
Ron

**P.S. While I am a proponent of the later Wittgenstein’s view of language (in Philosophical Investigations), I don’t subscribe to the post-modern, Foucaultian view that sees psychiatric language as merely a collection of “oppressive discourses” or “epistemes,” etc. All this is very old stuff to me, Brent, since I debated a certain faculty member at Upstate Medical University, by the name of Thomas Szasz, way back in 1979, during my residency! (see, e.g., Pies R, “On Myths and Countermyths: more on Szaszian Fallacies, Archives of General Psychiatry, Feb. 1979; and also my chapter in Jeffrey Schaler’s book, “Szasz Under Fire.”) Of course, I recognize that Szasz and Foucault have quite different reasons for their positions, and I have outlined these in my chapter. As a final comment on Foucault, see Ian Hacking’s astute observation that, “Despite all the fireworks, “Madness and Civilization” follows the romantic convention that sees the exercise of power as repression, which is wicked.” [Hacking I, The Archaeology of Foucault, in Hoy, Foucault, A Critical Reader (Oxford, 1986)].

^^I am aware of recent genetic data suggesting that schizophrenia and bipolar disorder may be genetically related, and that a strict, categorical separation of the two may prove, someday, to be inaccurate. But we do the best we can with the information now at hand. We can, if necessary, create a new category of “schizopolar
disorder”, as we learn more about the genetic relationship between these syndromal diagnoses.
I am also aware that the term “schizophrenia” identifies a heterogeneous group; this is no surprise–Bleuler used the term, “schizophrenias” as early as 1911. So, too, outcome and response to treatment may be quite variable in schizophrenia, and schizophrenia by no means predicts the inevitable, downhill course that used to characterize textbook descriptions. Nonetheless, longitudinal studies show, for example, that those diagnosed with schizophrenia have a poorer long-term outcome than that seen with affective disorders [see Lang et al, Acta Psychiatr Scand. 2013 Mar;127(3):173-82. Thanks to Dr. Joe Pierre for this reference].

Tim Carey-May 30th, 2013 at 1:27 amnone
Comment author #51 on After the DSM-5, Then What? The Future of Diagnosis in Psychiatry and Clinical Psychology by Global Summit on Diagnostic Alternatives

Thanks for this summary of important current developments Brent. Like you, I think the problem formulation approach holds a lot of promise. It has the ability to incorporate biological, psychological, and social elements and, as such, could be a useful integrative strategy.

I, too, think we’re living in an exciting time. There’s a real chance to make substantial progress in the way we understand and support people experiencing psychological distress. I’m excited at the possibilities that forums like this one might generate.